Four Trends in Claims Management

Now that #ASHRM2016 is a wrap, it's time to look back on what we learned and what we need to focus on for the rest of 2016. Heidi recently attended several sessions at ASHRM and shares with us the legislative trends and emerging risks in claims management. If you work in risk or claims management, you’re going to want to read this!

Cyber risk can equal patient risk
Not only is cyber risk about protecting personal health information (PHI) but devices can be at risk from cyber-attacks. For example, infusion pumps, insulin pumps and pacemakers can be at risk and, if they’re hacked, it can be a matter of life or death! When it comes to an information risk analysis at your organization, you must know where all of the exposures are.

Educate yourself on EMTALAEMTALA is a complicated piece of legislation aims to improve patients’ experiences and outcomes in emergency departments. Where that can become an issue for claims managers is interpreting and understanding all of the different regulations (CMS definitions, state laws and the federal EMTALA law) especially when it comes to psychiatric patients. Start reading!

Be prepared to deal with False Claim Act violations
Directors & Officers (D&O) liability coverage is limited and may be inadequate. While applying for coverage, connect with all of the subject-matter experts at your organization, including compliance officers and legal counsel.

Any claim submitted to the government is subject to FCA. As these new types of major lawsuits emerge, they can pay out unexpectedly high verdicts. In one major verdict case, the payments to the government were upwards of $389 million for systematically discarding expensive dialysis drugs and billing the government for wasted drugs. Common types of FCA cases include: